Marijuana: The Inevitable Progression from Medical to Recreational Use Kirk Moberg, MD, PhD, FASAM Medical Director, Illinois Institute for Addiction Recovery Clinical Professor, Departments of Internal Medicine and Psychiatry & Behavioral Medicine University of Illinois College of Medicine Illinois Alcohol and other Drug Abuse Professional Certification, Inc. March 17, 2016 Agenda • Cannabis: the basics • Our society’s relationship with marijuana • Cannabis is an addictive drug • The arguments for and against a medical role • Unintended outcomes • The revenues and costs of legalization Give credit where credit is due Kevin Sabet, PhD Nora Volkow, MD CANNABIS: THE BASICS Cannabis sativa 483 compounds 84 cannabinoids Hemp Hemp stalk Compressed hemp seeds Paper, construction material, clothing, biofuels Hemp seeds Eaten raw, hemp milk, hemp juice, hemp milk ice-cream, waffles, tofu, nut butters The psychoactive parts Leaves Buds FLowers D-9-tetrahydrocannabinol identified 1964 Flowers and leaves More potent derivatives Kief: trichome rich powder Hashish: pressed kief, detached trichomes, and fine material that falls from leaves or scraped resin Trichomes Hash Oil Organic solvent Cannabis or Hash oil Hashish Consequences Burns in Colorado Self admitted MJ users treated for burns 18 16 14 12 10 Self admitted MJ users 8 treated for burns 6 4 2 0 2010 2011 2012 2013 2014 Dabbing 80% Several explosions and fires have been reported due to BHO extractions done indoors with open-air blasting methods. Recently, a 2- year-old child had to be helicoptered from Eureka to Sacramento for medical treatment after a butane explosion in his home caused severe burns on his body. “Another danger of “dabbing” cannabis oils is passing out after a particularly strong dose. At a recent conference, there were at least three different emergency calls due to use of high- potency cannabis extracts. One person fainted and cracked his nose on the sidewalk, in another case of woman broke her teeth on the floor. Is there a reluctance to call that an overdose? OUR SOCIETY’S RELATIONSHIP WITH MARIJUANA The pendulum swings the other way April 28, 2014 Dichotomy Past month use Risk: past year Risk: daily use “We will use [medical marijuana] as a red-herring to give marijuana a good name.” Keith Stroup, head of NORML, 1979. “Cannabis is one of the safest drugs ever in the pharmacopeia. Period.” Allen St. Pierre, Director of the National Organization for the Reform of Marijuana Laws, 1999. CANNABIS IS AN ADDICTIVE DRUG Cannabinoid receptors CB1 and CB2 CB1 receptors—brain CB2 receptors—immune system suppression; pain MRI Scans of Healthy Children and Teens Over Time GM loss = maturation Copyright ©2004 by the National Academy of Sciences Gogtay, Giedd, et al. Proc. Natl. Acad. Sci., 2004 DSM-5: CANNABIS USE DISORDER • A. A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period – Is often taken in larger amounts or over a longer period than was intended – Persistent desire or unsuccessful efforts to cut down – Great deal of time spent in activities necessary to obtain, use or recover from effects – Craving, or strong desire to use – Failure to fulfill major role obligations at work, school or home – Continued use despite problems as a result – Important social, occupational or recreational activities are given up or reduced because of use – Recurrent use where it is physically hazardous – Continued use despite knowledge of a physical or psychological problem that is known to be caused or exacerbated by it – Tolerance – Withdrawal 45,570 patients followed longitudinally in Sweden—15 year follow up Lancet, 1987 Dunedin study (IQ) • 1037 patients • Followed from birth to age 38 • Cannabis use ascertained at age 18, 21, 26, 32, 38 • Neuropsychological testing at 13, before initiation of cannabis use, at 38, after pattern of use had developed Meier et al., 2012 Results (additional diagnoses hypothesis) Hard drugs= amphetamines, cocaine, heroin Adolescent vs. adult number of times meeting diagnostic criteria Post cessation Infrequent = weekly or less often Criticisms • Socioeconomic factors—IQ correlates with socioeconomic status • Socioeconomic factors—use of cannabis correlates with socioeconomic status • Education—lack of education correlates with IQ Response and re-evaluation • Original paper did address education • Authors re-evaluated socioeconomic status, ran the data and there was no difference National Epidemiologic Survey on Alcohol and Related Conditions 2001-2002; 43,093 respondents, non-institutionalized, 18 years of age and older Junk on the internet What is harm anyway? • Mental illness • Respiratory illness – Acute and chronic bronchitis – COPD • Cardiovascular illness – ED visits for tachycardia but studies limited More Adverse Effects of Short-Term Use and Long-Term or Heavy Use of Marijuana. Volkow ND et al. N Engl J Med 2014;370:2219-2227 Level of Confidence in the Evidence for Adverse Effects of Marijuana on Health and Well- Being. Volkow ND et al. N Engl J Med 2014;370:2219-2227 Ferguson and Boden, 2008 Drugged driving Meta-analysis: Drivers who tested positive or self- reported were more than twice as likely to be involved in a crash. 85% of Washington drivers involved in fatal crashes are positive for THC. Mu-Chen Li, 2011 THE ARGUMENTS FOR AND AGAINST A MEDICINAL ROLE Increases over Time in the Potency of Tetrahydrocannabinol (THC) in Marijuana and the Number of Emergency Department Visits Involving Marijuana, Cocaine, or Heroin. Volkow ND et al. N Engl J Med 2014;370:2219-2227 Cannabidiol:THC Dravet syndrome Colorado Timeline • 2001—Medical marijuana in Colorado • 2005—Denver legalizes possession • 2007-08—First stores • 2009—700 stores; 3.5% of adults have MMJ license • 2012—Legalized • 2014—Recreational stores open Doctors supported this We know how this turned out Cannabis for medical purposes • Illinois—45 • Alaska—10 • New Mexico—20 • Hawaii—9 • Washington—17 • Minnesota—9 • Arizona—16 • California—8 • New York—15 • Colorado—8 • Michigan—14 • Washington DC—8 • Maine—12 • Georgia—8 • New Jersey—12 • Massachusetts—8 • Rhode Island—12 • Nevada—8 • Delaware—11 • Vermont—7 • Montana—11 • New Hampshire—7 • Connecticut—11 • Maryland—5 • Oregon—10 • Louisiana—3 Jurisdictions where recreational use is legal Don’t worry, I won’t read all of these AIDS, Alzheimer’s Disease, ALS, Arnold-Chiari Malformation and Syringomyelia, Autism, Cachexia/Wasting Syndrome, Cancer, Causalgia, Chronic Inflammatory Demyelinating Polyneuropathy, Chronic Pain due to Trauma, Chronic Pain (post-operative), Chronic Pain Syndrome, Crohn’s disease, Complex Regional Pain Syndrome Types I and II, Dystonia, Fibromyalgia (severe), Fibrous Dysplasia, Glaucoma, Hepatitis C, HIV, Hydrocephalus, Interstitial Cystitis, Intractable Pain, Irritable Bowel Syndrome, Systemic Lupus Erythematosis, Multiple Sclerosis, Muscular Dystrophy, Myasthenia Gravis, Myoclonus, Nail-Patella Syndrome, Neurofibromatosis, Osteoarthritis, Parkinson’s Disease, Post-Concussion Syndrome, PTSD, Residual Limb Pain, Rheumatoid Arthritis, Seizures, Sjogren’s Syndrome, Spinal Cord Disease, Spinal Cord Injury, Spinocerebellar Ataxia, Tourette Syndrome, Traumatic Brain Injury As of October 2015 Louisiana Symptoms Related to Cancer Chemotherapy, Glaucoma, Spastic Quadriplegia California Cancer, Anorexia, AIDS, Chronic Pain, Multiple Sclerosis, Epilepsy, Glaucoma, Arthritis Not done yet… “any other chronic or persistent condition which limits a major life activity and is capable of causing serious harm” So, we have a patient with Parkinson’s disease Mono-amine oxidase inhibitor Shall we prescribe tobacco? So, how do we get from… Point A—no legalization to… Point B—legalization for medicinal purposes This doesn’t do it This does Compassionate care or Increased access to marijuana? <5% Less than 5% of card holders are cancer, HIV/AIDS or glaucoma patients. Avg patient: 32 year old WM; history of drug abuse; no life threatening disease Vocabulary • THC—D-9-tetrahydrocannabinol • Dronabinol (Marinol®) • Nabilone • Cannabidiol (Epidolex®) • Nabiximols (Sativex®; 1:1 ratio of THC:CBD) • Levonantradol (not in clinical use) The data • 79 trials • 6462 patients • HIV/AIDS appetite stimulation • Nausea and vomiting due to chemotherapy • Chronic pain • Spasticity due to multiple sclerosis or paraplegia • Depression • Anxiety disorder • Sleep disorder • Psychosis • Glaucoma • Tourette syndrome Conclusions • 4 articles judged low risk of bias Conclusions • Best evidence is for chronic pain of a variety of sorts • Suggestion of benefit for spasticity in MS and paraplegia Whiting et al., 2015, Cannabinoids for Medical Use: A Systematic Review and Meta-analysis, JAMA More data • 34 studies • Class I (8) • Duration (1948-2013) Medications used • Oral cannabis extract • Nabiximols • THC Results • Spasticity—OCE effective; Nabiximols, THC probably effective • Central pain or painful spasms including spasticity related pain—OCE effective; Nabiximols, THC probably effective • Urinary dysfunction—Nabiximols probably effective for decreasing number of voids; THC, OCE probably ineffective • Tremor—THC, OCE probably ineffective, Nabiximols possibly ineffective • L-dopa induced dyskinesia in Parkinson’s—OCE probably ineffective • Non-chorea symptoms of Huntington disease, cervical dystonia, epilepsy, Tourette syndrome—oral cannabinoids unknown efficacy Koppel et al., 2014, Systematic Review: Efficacy and safety of medical marijuana